23A-021 (5) 17 PARK ST BP-2016-1101
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A-021 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2016-1101
Project# JS-2016-001882
Est. Cost: $2423.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq. ft.): 7187.40 Owner: QUIGLEY KATHY
Zoning: URB(100)/ Applicant: JOHN PERRIER
AT. 17 PARK ST
Applicant Address: Phone: Insurance:
18 BROADWAY POND RD (860)930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON:3/22/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 3/22/2016 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
17 PARK ST BP-2016-1101
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A-021 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2016-1101
Project# JS-2016-001882
Est. Cost: $2423.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Cass: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sc. ft.): 7187.40 Owner: QUIGLEY KATHY
Zoning: URB(100)/ Applicant: JOHN PERRIER
AT. 17 PARK ST
Applicant Address: Phone: Insurance:
18 BROADWAY POND RD (860)930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON.•3/22/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC INSULATION
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 3/22/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1101
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 18 BROADWAY POND RD STAFFORD SPRINGS06076(860)930-7794
PROPERTY LOCATION 17 PARK ST
MAP 23A PARCEL 021 001 ZONE URB(100)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE
Fee Paid 4P sa(yo
Building Permit Filled out
Fee Paid
Tyneof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 105319
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOR ATION PRESENTED:
pproved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission _Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
0 ' ' lay
SC Of icia Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
�wl�w�lw
Ei
1i i 5
sachusetts
OF ` . =tiand Standards FOR
OF FtUILTI`; ]"c R"" FGT! MUNICIPALITY
ORI r.ns Ow,VA 0103 chusetts State Building Code, 780 CMR
USE
Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building.Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 11.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Municipal❑ On site disposal system 13Public❑ Private❑ Check if yes❑ p p y
SECTION 2: PROPERTY OWNERSHIP'
2,k Ow er'of Jecord
h'�� l h
Name(Pr' ) ity S te,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2:
To Add R-38 Insulation too en attic
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: ----�'
Check No. Check AmounA Cash Amount:
6.Total Project Cost: $ 3 ❑Paid in u ❑Outstanding Balance Due:
NEGH
28 Spellman rd
Please Submit Stafford Springs,Ct
Permits to: 06076
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
John Perrier 105319 12-12-2015
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) 1
18 Bradway Pond rd
Type Description
No.and Street U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Mason
ry
RC Roofing Covering
Stafford Springs Ct 06076 WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
860-930-7794_ jperrier06O76@yahoo.com
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 173021 5-27-2016
HIC Company Name or HTC Registrant Name
Join Perrier HIC Registration Number Expiration Date
No.and Street jperrier06076@ynhoo.eom
18 Bradway Pond rd Email address
Stafford Springs,Ct.06076
Ci /'Town State ZIP Telephone 860-930-7794
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152.$ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes..........I No...........17
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize New England Green Homes to act on my behalf,in all matters
relative to work authorized by this building permit application.
John Perrier
/ V/2016
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Lynn Ford 31
13/2016
Print Owner's or Authorized Agent's Name Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
91, The Commonwealth of Massachusetts Print
Department of Industrial Accidents
Office of Inveftations
IF X Congress Street,Suite IOU
Boston,MA 02114.2017
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricions/Plumbem
AoRlicUt Information -Pleale-PleaPrint Legibly
Name(Busittesslorganization/individual):New England Green Homes
Address:18 Bradway Pond rd
City/State/Zip:Stafford Springs Ct Phone#:06076
Are you so employer?Check the appropriste box:
✓ 4 4. I am a general contractor and I Type of project(required),
1.'� [iitr,a employer with B 6. ❑New construction
employees(full and/or part-time).' have hired idle sub-contractors
2. 1 am a solo proprietor or partner- listed on the attached sheet, 7. Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
(No workers'comp,insurance comp. insurance.'
required.) 5. [3 We are a corporation and its 10.El Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LEI Plumbing repairs or additions
myself.[No workers' comp, right of exemption per MGL 12.E3 Roof repairs
insurance required.]t c. 132,§1(4),and we have no
employees.[No workers' 1321 Qthorinsulation
comp, insurance required.)
+Any applicant that checks box ill must also fill out the section below showing their workers'compensation policy Information.
t}tomaowners whosubmit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entitiet have
employoea. if the subcontractors have employees,they must provide their workers'comp.policy number.
1 am an employer that isprovfding workers'compensation insurance for my employees. Below is the policy and fob site
informadon.
Insurance Company Name:lntego
Policy N or Self-ins.Lia#:NEWC634866 Expiration Date:08/2016
Job Site Address-,All Streets In City/State/Lip' �1 �` l� Mki
Attach a copy of the workers'compensation policy declaration page(showing tete policy number and expiration date). 0)a�1
Failure to secure coverage as required under Section 25A of MGI,c. 152 can Iced to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as we]]as civic penalties In the form of STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certtFyjunder the pains and enal 'es ofperlwy that the in orntation provided above Is true and correct.
aINIIIIIIIII 11 AI ..1 Ills
Ph n ! �•�l V
Ofllctal use only, Do not write In this area,to be completed by city or town o„jftelat
City or Town: Permit/License 0
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4,Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Verson: Phone if:
Installation Agreement Contract
a � c f•.IYEhGi.A.vD
REENHOME
�■I•' New England Green Homes
1(855)7EARTH7 Toll Free
413-244-2003 (Cle")
Info@ negreenhomes.com
Customer Name: 1�'�'�'� (I LA ezf
Address: �`r} �at( I� S //�f9,�JGI a'R-'0J* F/Dst{{M2t s Ana
Home Phone: Cell:
Client Number:-
Work Descri do . r10Ci1i S1 �J
2 ! `72-Z.G..
/ ttll
,A Y t, lJ
/� cG r ^7
AL, P-1
4 Est , 6z32- 1401,
Job Total: y%�3— incentive A aunt: �l7
Customer Cost: 0f, Install Date &'1h
Please Refer to the Home Energy Report for a detailed description of work to be preformed
,2 b7 cK s� >,���.
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
The contractor agrees to perform the above described work,furnishing the materials and labor specified above for the total price
listed above. Payment of the full amount is expected upon completion,by check,cash or credit.
The customer agrees to pay the balance of the cost upon completion of the job.
Customer Signature: Date: 2/ S- �
Contractor Signature: Date: Z-
rr- City of Northampton
Massachusetts F`:° :k. .�
DEPARTMENT OF BUILDING INSPECTIONS
212 Bain Street • Municipal Building
Northampton, MA 01060
Property Address: ��
Contractor ) 11 ��
Name:Address: Qdzd
City, State:
Phone: tf l Jt� 7 7 q�l
Property Owner
Name:
Address: 1-7 ,kl
City, [p
I i (contractor)attest and affirm that the Building f intend to
insul a doe not ave any open air(knob and tube)wiring in the spaces to be insulated and that I have
provided th erty owner with a copy of this affidavit.
r
Contractor signature
Date